Data on Medicaid Managed Care Payments to Providers Are Incomplete and Inaccurate

WHY WE DID THIS STUDY

Effective oversight of Medicaid requires a national system with complete and accurate data. The Centers for Medicare & Medicaid (CMS) established the Transformed Medicaid Statistical Information System (T-MSIS) for this purpose. Payment data are a critical component of T-MSIS. These data include the amounts paid, billed, and allowed for every service provided to Medicaid enrollees, including those services provided through managed care.

Managed care has become the primary delivery system for Medicaid. Each managed care plan provides the State with data about what the plan paid providers for their encounters with Medicaid enrollees. The State is then required to submit these data to T-MSIS. The Office of Inspector General (OIG) and others have consistently identified deficiencies in the quality of T-MSIS data, including particular concerns with the quality of data for managed care.

CMS and others rely on T-MSIS data to provide oversight; to identify trends; and to detect fraud, waste, and abuse. States also use payment data to set the capitation rates paid to managed care plans for each enrollee and to monitor the services provided by the plans.

HOW WE DID THIS STUDY

We analyzed the payment data from the encounter claims in T-MSIS for January 2020 for the largest managed care plan in each of the 39 States that provide comprehensive, risk-based managed care.

WHAT WE FOUND

Most States did not provide complete or accurate payment data in T-MSIS on managed care payments to providers; two States failed to provide any data for January 2020. Notably, about half of States did not provide complete or accurate information about the amounts that managed care plans pay to providers for services-the amount paid. Almost three-quarters of the States provided incomplete or inaccurate information about the maximum amounts that managed care plans allow for services-the amount allowed. Over a quarter of the States provided incomplete or inaccurate information about the amounts that providers bill managed care plans for services-the amount billed.

With the rise in Medicaid enrollment and changes in utilization, the COVID-19 pandemic has demonstrated how essential it is to have complete and accurate national Medicaid data. T-MSIS data are more important than ever to ensure proper oversight and that Medicaid funds are spent appropriately. These data can be used to identify emerging trends as well as to inform public health efforts.

WHAT WE RECOMMEND

We recommend that CMS review States' managed care payment data in T-MSIS and ensure that States have corrective action plans to improve data completeness and quality, as appropriate. Further, CMS should make public its reviews of States' managed care data. Finally, CMS should clarify and expand its initiative on payment data. CMS did not concur with any of our three recommendations. CMS noted that it has already set priority areas for improving the reporting of T-MSIS data and it will continue to assess how to further expand data quality improvement efforts. We continue to press CMS to take the recommended actions to improve the managed care payment data in T-MSIS so that these data can be used to effectively monitor and oversee the Medicaid program.